Thromboprophylaxis Management in ICU Patient with Septic Shock, CKD 5 on HD, and Active GI Bleeding
This patient should receive mechanical thromboprophylaxis only (intermittent pneumatic compression devices) until the hematemesis resolves, at which point unfractionated heparin (UFH) 5,000 units subcutaneously every 8-12 hours should be initiated given her severe renal impairment. 1
Immediate Management: Mechanical Prophylaxis Only
Active gastrointestinal bleeding (hematemesis) is an absolute contraindication to pharmacologic thromboprophylaxis and requires mechanical prophylaxis as the sole intervention until bleeding resolves 1, 2
Initiate intermittent pneumatic compression devices immediately, as these have proven efficacy and are specifically recommended when anticoagulation is contraindicated 1, 3
Graduated compression stockings can be added unless contraindicated by peripheral vascular disease or severe edema 1
When to Transition to Pharmacologic Prophylaxis
Monitor daily for resolution of bleeding risk factors - once hematemesis stops and hemoglobin stabilizes without transfusion requirements, pharmacologic prophylaxis should be initiated 1
Critical Decision Point: Choice of Agent
Given this patient's CKD 5 on hemodialysis (creatinine clearance <30 mL/min), the choice of anticoagulant is crucial:
Unfractionated heparin (UFH) 5,000 units subcutaneously every 8-12 hours is the preferred agent for patients with severe renal impairment, as it does not accumulate and does not require renal clearance 1, 3
LMWH is generally preferred over UFH in septic patients with normal renal function 1, 3, but this patient's CKD 5 status makes UFH the safer choice
If dalteparin is available, it can be used as an alternative LMWH with low renal metabolism, though UFH remains the gold standard in this setting 1
Monitoring Requirements
Check platelet count before initiating any heparin therapy and monitor every 2-3 days for heparin-induced thrombocytopenia (HIT), which occurs in up to 30% of heparin-treated patients 2
If platelet count falls below 100,000/mm³ or if new thrombosis develops, immediately discontinue heparin and evaluate for HIT/HITT 2
Monitor for recurrent bleeding daily - check hemoglobin, observe NGT output, and assess for melena 4, 5
Coagulation monitoring (aPTT) is not required for prophylactic-dose UFH 2
Combination Therapy After Bleeding Resolves
Once pharmacologic prophylaxis is initiated, continue mechanical prophylaxis concurrently - the combination of pharmacologic and mechanical prophylaxis is recommended for critically ill septic patients whenever possible 1, 3
Special Considerations for This Patient
Septic Shock Context
This patient has severe sepsis/septic shock, which carries a strong recommendation for VTE prophylaxis due to high thrombotic risk from immobility, inflammation, and critical illness 1, 3
Septic patients have significantly elevated VTE risk, with studies showing DVT incidence of 26-29% without prophylaxis versus 4-13% with prophylaxis 1, 3
Hemodialysis Considerations
Patients on chronic hemodialysis have better ICU outcomes than those with acute kidney injury requiring new dialysis, suggesting dialysis dependence alone should not influence aggressive VTE prevention 6
During hemodialysis sessions, the patient will receive systemic heparinization, which provides some additional thromboprophylaxis 2
Active Bleeding Risk Stratification
Hematemesis represents a major bleeding contraindication that must be respected 2
The FDA label explicitly warns against heparin use in "uncontrolled active bleeding state" and lists "ulcerative lesions and continuous tube drainage of the stomach or small intestine" as conditions requiring caution 2
However, the Surviving Sepsis Campaign acknowledges that when bleeding risk decreases, pharmacologic prophylaxis should be started 1
Common Pitfalls to Avoid
Do not use LMWH in this patient - despite being preferred in general septic populations, severe renal impairment (CKD 5) causes LMWH accumulation and increased bleeding risk 1
Do not delay mechanical prophylaxis - waiting for bleeding to resolve before starting any prophylaxis increases VTE risk unnecessarily 1
Do not use prophylactic anticoagulation while active hematemesis continues - the bleeding risk outweighs thrombotic risk during active hemorrhage 2
Do not forget stress ulcer prophylaxis - this patient has multiple risk factors (mechanical ventilation implied by ICU status, septic shock, coagulopathy risk) and should receive proton pump inhibitor or H2-receptor antagonist 1, 4, 5